Professional Documents
Culture Documents
To cite this article: Anthony P. Mannarino & Judith A. Cohen (2011) Traumatic Loss
in Children and Adolescents, Journal of Child & Adolescent Trauma, 4:1, 22-33, DOI:
10.1080/19361521.2011.545048
Although different types of childhood trauma have many common characteristics and
mental health outcomes, traumatic loss in children and adolescents has a number of dis-
tinctive features. Most importantly, youth who experience a traumatic loss may develop
childhood traumatic grief (CTG), which is the encroachment of trauma symptoms on
the grieving process and prevents the child from negotiating the typical steps associated
with normal bereavement. This article discusses the distinctive features of CTG, how
it is different from normal bereavement, how this condition is assessed, and promising
treatments for children who experience a traumatic loss.
Epidemiologic studies indicate that the majority of children in the United States have
experienced exposure to potentially traumatic events (PTEs). A recent population study
(Copeland, Keeler, Angold, & Costello, 2007) found that 68% of surveyed children had
experienced at least one PTE and more than half had experienced multiple traumas.
Another study (Lipschitz, Rasmussen, Anyan, Cromwell, & Southwick, 2000) similarly
documented that over 90% of children seen in an inner city pediatric clinic had expe-
rienced traumatic exposure. Although most children are resilient after trauma exposure,
others develop significant mental health problems including symptoms of posttraumatic
stress disorder (PTSD), depression, anxiety, behavior problems, substance use disorder,
and physical health problems. As many as 25% of children have significant PTSD symp-
toms following exposure to a PTE (Lipschitz et al., 2000), suggesting that this disorder
alone is a serious public health problem. The Adverse Childhood Experiences Study (Felitti
et al., 1998) demonstrated that traumatic experiences during childhood confer significantly
increased risk for many of the leading cases of early death in adulthood. Thus, youth in the
United States are in need of prompt identification and effective intervention for symptoms
related to trauma exposure.
Until the present time, child trauma treatments have been developed and tested for
specific traumatic experiences, so-called silo treatments (e.g., for child sexual abuse, com-
munity violence, domestic violence, war). However, the great majority of children in
all of these studies have experienced multiple types of traumas (e.g., Cohen, Deblinger,
Mannarino, & Steer, 2004; Lieberman, Van Horn, & Ippen, 2005; Stein et al., 2003),
thereby suggesting that studies of children affected by distinct types of trauma may, in fact,
be evaluating and treating largely overlapping populations. Moreover, Saunders (2003)
proposed that treatments that successfully target PTSD and other symptoms in children
experiencing one type of trauma are likely to successfully treat children who have the
Submitted August 28, 2009; revised March 19, 2010; accepted September 14, 2010.
Address correspondence to Anthony P. Mannarino, Department of Psychiatry, Allegheny
General Hospital, Four Allegheny Center, Pittsburgh, PA 15212. E-mail: amannari@wpahs.org
22
Traumatic Loss in Children and Adolescents 23
After a death, children are confronted with the reality of going forward with their
lives without their loved one. Wolfelt (1996) used the term “reconciliation” to describe this
process. Childhood bereavement experts (Wolfelt, 1996; Worden, 1996) have identified a
number of tasks as significant in the reconciliation process, including accepting the reality
of the loss; fully experiencing the emotional distress of the loss; adjusting to one’s environ-
ment and sense of self without the loved one; finding meaning in the loved one’s death; and
becoming engaged with other adults who can provide ongoing comfort, security, and nurtu-
rance. These tasks require children to tolerate sustained thoughts about the deceased loved
one and their past interactions with the deceased and to face and bear the pain associated
with the loss. It is important to note that children can experience intensely painful nor-
mal grief reactions that may include great sadness, periods of crying, and withdrawal from
peers and activities. Nonetheless, these normal grief reactions are not the same as traumatic
grief, and clinicians and researchers are faced with the challenge of distinguishing between
them. As discussed later, children with traumatic grief are unable to complete the tasks of
reconciliation because remembering the loved one typically serves as a trauma reminder,
with the subsequent development of trauma symptoms (Cohen & Mannarino, 2004).
CTG has been described as a condition in which children whose loved ones die under
traumatic circumstances develop trauma symptoms that impinge on the children’s ability to
progress through typical grief processes (Cohen, Mannarino, Greenberg, Padlo, & Shipley,
2002; Layne et al., 2001). As discussed elsewhere (Cohen & Mannarino, 2006), these
children get “stuck” on the traumatic aspects of their loved ones death such that when they
start to remember their loved one, including happy memories, their memories tend to segue
into thoughts about the terrifying or horrific manner in which the person died. When this
process occurs, children begin to avoid reminiscing about the loved one and may avoid any
reminders about the deceased because of the propensity of these reminders to stimulate the
children’s painful trauma memories.
CTG is different from uncomplicated bereavement in several ways. First, the nature
of the death is often (but not always) qualitatively different in cases of CTG, with these
deaths typically being from sudden, unexpected, tragic, and/or violent causes such as
suicide, homicide, accidents, war, terrorism, and disasters. When CTG results after med-
ical deaths, the medical causes are often from sudden conditions such as heart attacks or
strokes. However, CTG can also result from chronic medical conditions because children
may not anticipate or comprehend that their loved one was going to die. Accordingly,
for these children, the death may be unexpected and sudden. In a parallel way, deaths
from anticipated causes can be extremely disturbing to children if they observe fright-
ening events such as their loved one gasping for air, frantic attempts at resuscitation, or
severe bodily deterioration. Thus, any cause of death can lead to CTG as long as the child
subjectively experiences it as traumatic (Cohen & Mannarino, 2010).
Another way that CTG is different from normal bereavement is with regard to the
presence and severity of PTSD symptoms. Some PTSD symptoms, including sleep diffi-
culties, loss of interest in peer and other social activities, and trouble concentrating, can
normally be expected in bereaved children. However, core PTSD symptoms such as intru-
sive re-experiencing of the deceased’s death, persistent avoidance of death reminders or
even avoidance of reminders of the loved one, and hyperarousal as manifested through
angry outbursts or hypervigilence are less typical of uncomplicated bereavement but very
characteristic of CTG (Cohen & Mannarino, 2010).
It is important to recognize that developing CTG is not the norm for children who
lose loved ones, even if the cause of death is objectively traumatic. A good example of
the nonnormative nature of CTG is a study by Pfefferbaum and colleagues (1999) who
Traumatic Loss in Children and Adolescents 25
studied children who were directly affected by the bombing of the federal office building
in Oklahoma City in 1995. Specifically, they reported that although PTSD was significantly
associated with the loss of a loved one and the closeness of the relationship to the deceased,
the majority of children who lost loved ones did not report elevated PTSD symptoms or
functional impairment 7 weeks after the bombing (Pfefferbaum et al., 1999).
Another study with similar findings was reported by Brent et al. (1995). In a study
of adolescents who had friends who committed suicide, only 5% of these adolescents
reported persistent PTSD symptoms (Brent, Perper, & Moritz, 1993; Brent et al., 1995).
In another study by this same research group, siblings of adolescents who had commit-
ted suicide did not demonstrate an increased incidence of PTSD symptoms compared to a
control group who had not been exposed to suicide, despite the former group having pro-
longed grief symptoms (Brent, Moritz, Bridge, Perper, & Canobbio, 1996a, 1996b). Thus,
it appears that the majority of children who lose loved ones under traumatic circumstances
do not develop CTG, and development of persistent PTSD symptoms that intrude on chil-
dren’s ability to grieve should not be viewed as normative for such children (Cohen &
Mannarino, 2004).
caused by the traumatic death. Attending a new school or having one’s aunt attend a class
play instead of one’s mother who died may be change reminders for these children (Cohen
& Mannarino, 2004).
In CTG, trauma reminders, loss reminders, and change reminders may all segue into
memories, thoughts, and images of the traumatic nature of the loved one’s death and may
be accompanied by physiological symptoms of hyperarousal. To illustrate, when a child
whose sister committed suicide in her bedroom at the family’s residence enters her bed-
room (a trauma reminder), he or she may have intrusive images of the sister lying on the
floor in a pool of blood and experience heart palpitations and intense anxiety (i.e., PTSD
re-experiencing and hyperarousal symptoms). The distress that such children experience
on exposure to trauma, loss, or change reminders leads them to try to avoid such exposure
in order to minimize their distress. For example, the child described previously may refuse
to enter the sister’s bedroom or even experience significant distress when he or she is on
the same floor as the sister’s room. Such avoidance may result in these children having less
exposure to trauma, loss, or change reminders or at least reduce their intensity (Cohen &
Mannarino, 2004).
However, when children have lost a loved one, these reminders are typically ubiquitous
and usually impossible to totally avoid. Some children may develop emotional numbing to
cope with those unavoidable or uncontrollable reminders. Numbing may take the form
of extreme detachment or estrangement in which children feel different and set apart and
alienated from others, even those in his or her own family or circle of friends who may
have experienced the same traumatic loss (Nader, 1997).
For children with traumatic grief, even thinking about happy times with their loved
one leads to thoughts, memories, and emotions related to the traumatic nature of the per-
son’s death. This, in turn, sets off the cascade of reactions described previously in which
reminiscing about the loved one leads to thoughts of the horrible way in which the person
died and which then results in PTSD symptoms (re-experiencing, hyperarousal, physio-
logical hyperreactivity, and intense psychological distress). These are extremely disturbing
symptoms for children and hasten the development of numbing and/or avoidance, which
in turn interfere with the child’s ability to reminisce about the loved one. Thus, in CTG,
PTSD trauma symptoms impinge on the child’s ability to reminisce about the loved one
and to achieve reconciliation, which is necessary for the successful negotiation of normal
bereavement (Cohen & Mannarino, 2004). As Pynoos (1992) stated, “It is difficult for a
child to reminisce . . . when an image of . . . mutilation is what first comes to mind” (p. 7).
This is the essence of the current concept of CTG.
Children with traumatic grief may blame themselves for the death of the loved one
or feel intense guilt that their loved one has died while they have survived. This may be
particularly true in large mass disasters (e.g., weather-related events or terrorism; Nader,
1997; Pynoos & Nader, 1990). Additionally, some children may develop rescue or revenge
fantasies. In the former, some children may unrealistically blame themselves for not being
able to rescue or save the deceased person and may develop rescue fantasies in which they
successfully do so. Revenge fantasies may also occur in which children imagine that they
hurt or punish the individual(s) who are responsible for the death of their loved one (Eth &
Pynoos, 1985).
Children face additional challenges when their loved one dies in circumstances to
which society attaches a stigma. Such circumstances might include suicide, homicide that
is drug-related, or death as part of family or domestic violence. In these situations, children
may experience significant embarrassment and shame (Eth & Pynoos, 1985; Nader, 1997).
Unlike children whose loved ones died in circumstances viewed as heroic (e.g., police
officers or rescue workers who die in the line of duty), these children typically do not
receive an outpouring of public sympathy or financial support. It is possible that the added
stigma or negative community judgment about the manner of death may constitute a risk
factor for developing CTG (Cohen & Mannarino, 2004).
After the death of a family member, children may experience secondary adversities
such as the loss of the family’s home, family income, or health insurance. If the family
has to relocate, children may also be required to change schools and be faced with loss of
close friends, a new peer group, different place of worship, and a completely unfamiliar
social support system. These adjustments can be extremely stressful even in the absence of
losing a loved one but are added burdens after a family member has died. These adversities,
as well as preexisting family stressors, increase children’s likelihood of developing CTG
(Cohen & Mannarino, 2004).
The ability to comprehend death and master the tasks associated with grief and trauma
depend on children’s cognitive and emotional development, at least in part. Accordingly,
some authors have suggested that children at different developmental levels may manifest
traumatic grief in unique ways consistent with their developmental stage (Nader, 1997;
Pynoos, 1992; Pynoos & Nader, 1990). To date, however, there has not been any empiri-
cal research to support the concept of developmental variation in the clinical presentation
of CTG.
Discussions about developmental variation in CTG are further complicated by the
ongoing controversy regarding the diagnostic criteria for and clinical assessment of PTSD
symptoms in very young children. Specifically, child PTSD researchers have raised con-
cerns that the current diagnostic criteria for PTSD (e.g., presence of three avoidance
symptoms) are not appropriate for young children and need to be modified. Moreover, no
consensus exists regarding how PTSD symptoms should be evaluated in this young popu-
lation (e.g., interview with parent only vs. combination of child and parent interviews).
Accordingly, at the present time, it is difficult to support the notion of developmen-
tal variation in the clinical presentation of CTG when the nature and assessment of
PTSD symptoms (a necessary but not sufficient condition for traumatic grief) in very
young children have not achieved any type of consensus among experts in the field
(Cohen et al., 2002).
Parental response may have a significant impact upon the development and intensity
of traumatic grief in children (Nader, 1997; Pynoos & Nader, 1990). Particularly when a
parent has died, the surviving parent may have increased caretaking responsibilities and
work demands that can result in higher levels of general distress as well as irritability
28 A. P. Mannarino and J. A. Cohen
and fatigue. These symptoms can reduce the parent’s emotional availability and affect the
consistency of parenting (Nader, 1997). Moreover, a parent’s own avoidance can make it
difficult to tolerate a child’s expression of normal grief symptoms. Thus, the combination
of parental distress and avoidance can make it more probable that a child will develop
traumatic grief (Nader, 1997).
Observing a child’s grief and pain over the loss of a loved one is extremely hard for
most parents. They may feel that their child has been through “too much” and that the world
is no longer a safe place. In response to these perceptions, parents may become lax in their
limit setting or overly protective, both of which can create increased insecurity and anxi-
ety in the child. If normal routines are disrupted and children are not permitted in engage
in activities consistent with their developmental level (e.g., sleepovers, school activities),
they will likely begin to perceive their world as unsafe and unpredictable. This, in turn,
will make it harder for children to negotiate the normal grieving process and contribute to
persistent symptomatology. It should be noted that parental emotional distress in response
to traumatic events and lack of parental support are associated with more severe and persis-
tent PTSD symptoms in some cohorts of traumatized children (Cohen & Mannarino, 1996,
2000). Empirical research is needed to determine whether such associations are present in
CTG as well (Cohen et al., 2002).
A number of studies have examined mediating factors in symptom formation follow-
ing the traumatic death of friends or family members; however, PTSD symptoms, not
traumatic grief, have been the primary focus (Malmquist, 1982; Pfefferbaum et al., 2000;
Pynoos et al., 1987). In these studies, severity of PTSD symptoms has been associated with
greater exposure, such as witnessing death (Pynoos et al., 1987) or the closeness of the rela-
tionship to the deceased (Brent et al., 1993; Brent et al., 1995; Cerel, Fristad, Weller, &
Weller, 1999). Additionally, Brent et al. (1996b) reported that having a conversation with
the deceased within the 24 hours before the deceased committed suicide predicted both
PTSD and depressive symptoms 3 years later. The latter study suggests the potential con-
tribution of perceived guilt, regret, and/or responsibility for the death in the development
of CTG, particularly in adolescents.
Assessment of CTG
The general assessment of CTG should include a comprehensive evaluation of the past
and current functioning of the child and family as would be the case in any psychiatric
or psychological evaluation. Additionally, the child’s experience and perceptions of the
loved one and his or her death, the child’s PTSD symptoms, and the encroachment of these
symptoms on the child’s ability to engage in the normal bereavement process should be
examined (Cohen et al., 2002).
Specific assessment procedures for children with possible traumatic grief have been
suggested by some authors. Pynoos and Eth (1986) developed an interview technique for
children exposed to trauma that can be used to assess the likelihood of traumatic grief.
As part of the interview process, the child describes the impact of the trauma through an
unstructured free drawing and storytelling task. The child is then encouraged to describe
the trauma in detail, including the “worst moment,” sensory details, and who was responsi-
ble for what occurred. Steinberg (1997) recommends a less structured interview approach
that is relationship-oriented. This approach evaluates the family’s history before the death,
the quality of family relationships, home atmosphere after the loss, available social support
system, the meaning of the death to the child, and the child’s hopes and plans for the future
(Cohen et al., 2002).
Traumatic Loss in Children and Adolescents 29
Although there has been increased empirical attention over the past decade to recog-
nizing and defining CTG and identifying its correlates, there has been relatively little work
in the area of developing psychometrically sound assessment instruments to evaluate it.
Thus, there are few options in terms of validated assessment instruments. The UCLA/BYU
Expanded Grief Inventory (EGI; Layne et al., 2001) is the only published instrument that
assesses CTG and has been validated by two independent groups (Brown & Goodman,
2005; Layne et al., 2001). The EGI includes 28 items to which children respond on a
5-point Likert scale. The EGI is appropriate for children ages 7 to 17 years (Layne et al.,
2001). Factor analysis (Layne et al., 2001) has revealed distinct scales for uncomplicated
bereavement (i.e., able to experience positive memories, dreams, conversations, and con-
nections with the deceased) versus traumatic grief (i.e., traumatic intrusion and avoidance
interfering with normal bereavement). The Characteristics, Attributions and Responses to
Exposure to Death-Youth and Parent Versions (CARED-Y and CARED-P; Brown et al.,
2008) is a 39-item self-report measure that gathers information about peritraumatic aspects
of the loved one’s death as well as information about the child’s premorbid relationship
with the deceased and participation in mourning rituals. The psychometric properties of
the latter instrument are reasonable despite it being a relatively new instrument (Brown &
Goodman, 2005; Brown et al., 2008). There is no validated instrument available to assess
CTG in very young children (Cohen & Mannarino, 2010).
components in TG-CBT include grief education, grieving the loss and resolving ambiva-
lent feelings about the loved one who died, preserving positive memories, and redefining
the relationship with the person who died to one of memory.
It should be noted that the parallel sessions with the parent or caretaker are critical to
TG-CBT as they are with TF-CBT. In this regard, parents are provided psycho-education
about how children of different ages perceive death so that they can better understand what
their children are experiencing. Also, behavior management is an important part of the
parent sessions to address any ongoing behavioral problems. Joint sessions with the child
and parent can be used to help the family to anticipate future loss and change reminders
(e.g., anniversaries, graduations, birthdays) and to develop plans to effectively cope with
the painful memories these important events may evoke.
There is beginning to emerge some empirical support for TG-CBT, which suggests
that it has the potential to help children suffering from traumatic grief. In two open trials
(i.e., no comparison or control group) of TG-CBT, children suffering from traumatic grief
had significant reductions in CTG and PTSD symptoms (Cohen, Mannarino, & Knudsen,
2004; Cohen, Mannarino & Staron, 2006). Also, there has been one randomized clinical
trial (RCT) involving TG-CBT that was conducted in the New York City area for children
whose uniformed parents died in the rescue efforts related to the September 11 terrorist
attack. In this investigation, Brown, Goodman, Cohen, and Mannarino (2004) reported
that the mothers in the TG-CBT group experienced significantly greater improvements in
PTSD symptoms and general distress than mothers in the client-centered therapy group.
There were no significant group differences in child outcomes.
Hurricane Katrina. Both pilot studies included youth exposed to homicide or other violence
(Salloum, 2006; Salloum et al., 2001) and both demonstrated significant improvement in
PTSD symptoms.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text revision). Washington, DC: Author.
Brent, D. A., Moritz, G., Bridge, J., Perper, J., & Canobbio, R. (1996a). The impact of adolescent
suicide on siblings and parents: A longitudinal follow-up. Suicide and Life-Threatening Behavior,
26, 253–259.
Brent, D. A., Moritz, G., Bridge, J., Perper, J., & Canobbio, R. (1996b). Long-term impact of expo-
sure to suicide: A three-year controlled follow-up. Journal of the American Academy of Child and
Adolescent Psychiatry, 35, 646–653.
Brent, D. A., Perper, J. A., & Moritz, G. (1993). Psychiatric sequelae to the loss of an adolescent peer
to suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 509–517.
Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., et al. (1995).
Posttraumatic stress disorder in peers of adolescent suicide victims, Predisposing factors and
phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry, 34,
209–215.
Brown, E. J., Amaya-Jackson, L., Cohen, J. A., Handel, S., Thiel de Bocanegra, H., Zatta, E., et al.
(2008). Childhood traumatic grief: A multi-site empirical examination of the construct and its
correlates. Death Studies, 32, 899–923.
Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: An exploration of the construct
in children bereaved on September 11. Journal of Clinical Child and Adolescent Psychology, 34,
248–259.
Brown, E. J., Goodman, R. F., Cohen, J. A., & Mannarino, A. P. (2004, April). Treatment of child-
hood traumatic grief: A randomized controlled trial. Paper presented in symposium “Childhood
Traumatic Grief” at Strengthening Our Future: Developing Healthy Children and Youth, Strong
Families and Safe Communities, Kansas City, MO.
32 A. P. Mannarino and J. A. Cohen
Cerel, J., Fristad, M. A., Weller, E. B., & Weller, R. A. (1999). Suicide bereaved children and ado-
lescents, a controlled longitudinal examination. Journal of the American of Child and Adolescent
Psychiatry, 38, 672–679.
Children’s Bereavement Center of South Texas. (2008). 2008 Report to our community. Retrieved
from http://www.cbcst.org/docs/AnnualReport.pdf
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite randomized con-
trolled trial for sexually abused children with PTSD symptoms. Journal of the American Academy
of Child and Adolescent Psychiatry, 43, 393–402.
Cohen, J. A., & Mannarino, A. P. (1996). Factors that mediate treatment outcome of sexually abused
preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35,
1402–1410.
Cohen, J. A., & Mannarino, A. P. (2000). Predictors of treatment outcome in sexually abused
children. Child Abuse and Neglect, 24, 983–994.
Cohen, J. A., & Mannarino, A. P. (2004). Treatment of childhood traumatic grief. Journal of Clinical
Child and Adolescent Psychology, 33, 819–831.
Cohen, J. A., & Mannarino, A. P. (2006). Treating childhood traumatic grief. In T. Rynearson (Ed.),
Violent death: Resilience and intervention beyond the crisis (pp. 479–490). New York, NY:
Routledge Press.
Cohen, J. A., & Mannarino, A. P. (2010). Childhood traumatic grief. In M. D. Dulcan (Ed.), Textbook
of child and adolescent psychiatry (pp. 509–516). Washington, DC: American Psychiatric
Publishing.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in
children and adolescents. New York, NY: Guilford.
Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley C. (2002). Childhood traumatic
grief: Concepts and controversies. Trauma, Violence and Abuse, 3, 307–327.
Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: A pilot
study. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 1225–1233.
Cohen, J. A., Mannarino, A. P., & Staron, V. (2006). Modified cognitive behavioral therapy for child-
hood traumatic grief (CBT-CTG): A pilot study. Journal of the American Academy of Child and
Adolescent Psychiatry, 45, 1465–1473.
Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic
stress disorder in childhood. Archives of General Psychiatry, 64, 577–584.
Eth, S., & Pynoos, R. S. (1985). Interaction of trauma and grief in childhood. In S. Eth & R. S. Pynoos
(Eds.), Post-traumatic stress disorder in children (pp. 171–186). Washington, DC: American
Psychiatric Press.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive
Medicine, 14, 245–258.
Finkelhor, D., Ormrod, R. K., Turner, H. A., & Hamby, S. L. (2005). Measuring poly-victimization
using the juvenile victimization questionnaire. Child Abuse and Neglect, 29, 1297–1312.
Layne, C. M., Pynoos, R. S., Saltzman, W. S., Arslanagic, B., Black, M., Savjak, N., et al.
(2001). Trauma/grief-focused group psychotherapy: School-based post-war intervention with
traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5, 277–290.
Lieberman, A. F., &Van Horn, P. (2005). Don’t hit my mommy! A manual for child-parent
psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press.
Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child-
parent psychotherapy with preschoolers exposed to marital violence. Journal of the American
Academy of Child and Adolescent Psychiatry, 44, 1241–1248.
Lipschitz, D. S., Rasmussen, A. M., Anyan, W., Cromwell, P., & Southwick, S. M. (2000). Clinical
and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary
care clinic. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1104–1111.
Traumatic Loss in Children and Adolescents 33
Malmquist, C. P. (1982). Children who witness parental murder, posttraumatic aspects. Journal of
the American Academy of Child Psychiatry, 25, 320–325.
Nader, K. O. (1997). Childhood traumatic loss, the interaction of trauma and grief. In C. R. Figley,
B. E. Bride, & N. Mazza (Eds.), Death and trauma, the traumatology of grieving (pp. 17–41).
Washington, DC: Taylor & Francis.
Nader, K. O., Pynoos, R. W., Fairbanks, L., & Frederick, C. (1990). Children’s PTSD reactions one
year after a sniper attack at their school. American Journal of Psychiatry, 147, 1526–1530.
Pfefferbaum, B., Gurwitch, R. H., McDonald, N. B., Leftwich, M. J. T., Sconzo, G. M.,
Messenbaugh, A. K., et al. (2000). Posttraumatic stress among young children after the death
of a friend or acquaintance in a terrorist bombing. Psychiatric Services, 51, 386–388.
Pfefferbaum, B., Nixon, S. J., Tucker, P. M., Tivis, R. D., Moore, V. L., Gurwitch, R. H., et al. (1999).
Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of
the American Academy of Child and Adolescent Psychiatry, 38, 1372–1379.
Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care, 11, 2–10.
Pynoos, R. S., & Eth, S. (1986). Witness to violence, the child interview. Journal of the American
Academy of Child Psychiatry, 25, 306–319.
Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Spencer, E., et al. (1987).
Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44,
1057–1063.
Pynoos, R. S., & Nader, K. (1990). Children’s exposure to violence and traumatic death. Psychiatric
Annals, 20, 334–344.
Rynearson, E. K. (2001). Retelling violent death. Philadelphia, PA: Brunner Routledge.
Salloum, A. (2004). Group work with adolescents after violent death: A manual for practitioners.
New York, NY: Brunner Routledge.
Salloum, A. (2006). Group therapy for children experiencing grief and trauma due to homicide and
violence: A pilot study. Unpublished manuscript.
Salloum, A., Avery, L., & McClain, R. P. (2001). Group psychotherapy for adolescent survivors
of homicide victims: A pilot study. Journal of the American Academy of Child and Adolescent
Psychiatry, 40, 1261–1267.
Saltzman, W. R., Pynoos, R. S., Layne, C. M., Steinberg, A .M., & Aisenberg, E. (2001). Trauma-and
grief-focused intervention for adolescents exposed to community violence: Results of a school-
based screening and group treatment protocol. Group Dynamics: Theory, Research, and Practice,
5, 291–303.
Saunders, B. E. (2003). Understanding children exposed to violence: Toward an integration of
overlapping fields. Journal of Interpersonal Violence, 18, 356–376.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., et al. (2003). A men-
tal health intervention for school children exposed to violence: A randomized controlled trial.
Journal of the American Medical Association, 290, 603–611.
Steinberg, A. (1997). Death as trauma for children, a relational treatment approach. In C. R. Figley,
B. E. Bride, & N. Mazza (Eds.), Death and trauma, the traumatology of grieving (pp. 123–137).
Washington, DC: Taylor & Francis.
Wolfelt, A. D. (1996). Healing the bereaved child: Grief gardening, growth through grief, and other
touchstones for caregivers. Fort Collins, CO: Companion Press.
Worden, J. W. (1996). Children and grief: When a parent dies. New York, NY: Guilford.